The influence of psychological flexibility on persistent post concussion symptoms and functional status after mild traumatic brain injury

Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study

OBJECTIVES

This study aimed to determine the feasibility of recruiting, implementing and delivering an acceptance and commitment therapy (ACT) intervention for mild traumatic brain injury (mTBI) (ACTion-mTBI) within a multidisciplinary outpatient mTBI rehabilitation services. The study also aimed to conduct a preliminary investigation of group differences between ACTion-mTBI and an equivalent cognitive behavioural therapy (CBT) intervention on various outcome measures and psychological treatment targets.

DESIGN

A two-arm quasiexperimental feasibility study.

SETTING

Five mTBI rehabilitation clinics throughout New Zealand.

INTERVENTION

Psychologists working in mTBI rehabilitation clinics throughout New Zealand were trained to deliver ACTion-mTBI or CBT. Eligible participants were assigned to either of these interventions based on the psychologist available at the clinic they were referred to. ACTion-mTBI is a five sessions intervention that incorporates all six components of the ACT model. The CBT intervention is an equivalent intervention and incorporating all four components of the CBT model. Both interventions are adapted for an mTBI context.

PRIMARY OUTCOME MEASURES

The primary outcomes were related to the feasibility of ACTion-mTBI. This included recruitment, retention and treatment adherence of participants, study procedure and fidelity of treatment delivery.

SECONDARY OUTCOME MEASURES

To explore group differences between ACTion-mTBI and CBT on functional disability, postconcussion symptoms, mental health, valued living and psychological flexibility.

RESULTS

The intervention proved feasible to implement with community-based mTBI rehabilitation services. Attrition rates were comparable between the two psychological interventions and fidelity to the treatments was high. At post-treatment, when covarying pretreatment scores, ACTion-mTBI had a significantly greater improvement in functional disability than CBT (moderate effect). ACTion-mTBI also had a significantly greater reduction in postconcussion symptoms, anxiety and stress. Promisingly, significant improvements in psychological flexibility was also found post-treatment. There were no group differences on depressive symptoms and valued living.

CONCLUSION

We conclude that a full clinical trial of ACTion-mTBI for individuals with mTBI is feasible and warranted.

TRIAL REGISTRATION NUMBER

ACTRN1262100059482.

Psychological Constructs From the Fear Avoidance Model and Beyond as Predictors for Persisting Symptoms After Concussion: An Integrative Review

OBJECTIVES

To identify the range of evidence for relationships between psychological factors using the Fear Avoidance Model (FAM) as a guiding framework and relevant clinical outcomes in adult patients with persisting symptoms after concussion (PSaC), develop a comprehensive understanding of psychological factors that have been identified as predictors of clinical outcomes for PSaC, and contribute to the theoretical framework of the FAM for PSaC.

DATA SOURCES

Six databases (CINAHL, Embase, PsycINFO, PubMed, SportDiscus, and Web of Science) were searched by a librarian for empirical and theoretical publications and experimental and quasi-experimental study designs. The literature search was not limited by publication date restrictions. Gray literature, with the exception of doctoral dissertations, was excluded.

STUDY SELECTION

We included studies in the English language consisting of human participants aged ≥18 years. Articles must have included both outcomes pertaining to PSaC (≥3mo after injury) and psychological constructs.

DATA EXTRACTION

One reviewer extracted data from the resulting studies using a standardized data extraction form designed for this review. Two reviewers independently assessed risk of bias using the Quality in Prognosis Studies tool.

DATA SYNTHESIS

This review found numerous psychological constructs, some directly linked to the FAM, that have potential prognostic relationships with PSaC. However, research remains limited and some psychological factors central to FAM were only identified in a small number of studies (catastrophizing, cogniphobia, and avoidance), whereas other psychological factors were studied more extensively (anxiety and depression).

CONCLUSIONS

There is the need for additional evidence, and this integrative review provides an adaptation of the FAM for PSaC to be used as a guiding preliminary framework for future research. Future research should aim to include psychological factors proposed in this modified FAM to fully understand PSaC.

Link between post-stroke psychopathology and scope-of-action awareness

Background

Epidemiological research has failed to confirm laterality of lesion site as a neurobiological source of post-stroke psychopathology. However, acquired communication disorders have proved to be a key risk factor for depression, apart from established parameters such as pre-stroke psychopathology and physical immobility.

Objectives

The present work examines a new predictor of post-stroke psychopathology: psychological flexibility. This concept describes an accepting attitude toward irreversible loss following stroke while using remaining agency.

Design

Overall, 70 individuals engaged in a cross-sectional study conducted in the subacute stage after an ischemic or hemorrhagic event, a period with elevated prevalence of mental-health problems (2 weeks to 6 months after stroke).

Methods

Outcomes included standardized self-report and clinician-rated measures of depression, anxiety disorders, and general psychopathology (Beck Depression Inventory; Hospital Anxiety and Depression Scale; ICD-10 Symptom Rating; Hamilton Depression Rating Scale) alongside lack of psychological flexibility (Acceptance and Action Questionnaire II). The study design controlled for pre-stroke psychopathology and physical immobility (Barthel Index).

Results

Partial correlation analyses revealed a significant medium-to-large association between the entire set of clinical outcomes and lack of psychological flexibility (r ⩽ 0.62, p < 0.001). In moderator analyses, the magnitude of this association did not vary significantly with diagnosis of acquired communication disorders (i.e., aphasia, apraxia of speech or dysarthria; separately or combined).

Conclusion

The current results demonstrate a substantial link between post-stroke psychopathology and psychological flexibility. This finding opens new avenues for research on depression and other mental-health problems in stroke survivors with and without acquired communication disorders.

Registration

www.drks.de; identifier: DRKS00031204.

Identification of At-Risk Patients That Need More Intensive Treatment Following mTBI: Post-Hoc Insights From the UPFRONT-Study

OBJECTIVE

To investigate which factors within an at-risk group make patients less likely to benefit from preventive treatment following mild traumatic brain injury (mTBI).

SETTING

Inclusion in 3 level I trauma centers in the Netherlands. Data collection through surveys as outpatients.

PARTICIPANTS

mTBI patients (18-66 years), reporting 3 or more complaints 2 weeks postinjury (at-risk status). Eighty-four patients included and randomized (39 patients cognitive behavioral therapy, 45 patients telephonic counseling). Eighty patients filled out the questionnaires 12 months postinjury. Post hoc analysis investigating 80 patients as 1 at-risk group receiving psychological treatment.

DESIGN

Post hoc study of a randomized controlled trial (RCT). Binomial logistic regression performed determining which variables 2 weeks postinjury contributed strongly to unsuccessful return to work/study (RTW) and unfavorable outcome at 12 months.

MAIN MEASURES

RTW and functional outcome as measured with the Glasgow Outcome Scale-Extended (GOSE) at 12 months postinjury.

RESULTS

Out of 80 patients, 43 (53.8%) showed a favorable functional outcome at 12 months, and 56 (70%) patients had a full RTW. Patients with unfavorable outcome had a higher age and higher reports of anxiety, depression at 2 weeks and 12 months postinjury. Patients with an unsuccessful RTW had a higher age and higher reports of depression, and posttraumatic stress disorder at 2 weeks and 12 months postinjury. A logistic regression model for functional outcome (GOSE) was statistically significant (χ² 7 = 40.30, P < .0001). Of 6 predictor variables, 3 were significant: anxiety, depression, and treatment condition. For RTW, logistic regression was also statistically significant (χ² 7 = 19.15, P = .008), with only 1 out of 6 predictor variables (ie, age) being significant.

CONCLUSION

Main findings comprise differences in demographic and psychological measures between patients with favorable and unfavorable outcomes and patients with RTW versus no RTW. Prediction models of outcome and RTW showed several psychological measures at 2 weeks greatly determining patients' likelihood benefitting from the preventive treatment. Results suggest that from the beginning there are some patients for whom a short preventive treatment is not sufficient. Selection and treatment of at-risk patients might be better based on psychological symptoms instead of posttraumatic complaints.

Concussion Rehabilitation and the Application of Ten Movement Training Principles

Concussion awareness continues to grow in all aspects of healthcare, including the areas of prevention, acute care, and ongoing rehabilitation. Most of the concussion research to date has focussed on the challenges around screening and diagnosing what can be a complex mix of brain impairments that overlay with additional pre-existing comorbidities. While we expect further progress in concussion diagnosis, progress also continues to be made around proactive rehabilitation, with the emergence of interventions that can enhance the recovery process, maximise function and independence with a return to study, work, and play. Traditionally, optimal multimodal assessments of concussion have treated the physical, cognitive, and psychological domains of brain injury separately, which supports diagnosis, and informs appropriate follow-up care. Due to the complex nature of brain injury, multimodal assessments direct care toward professionals from many different disciplines including medicine, physiotherapy, psychology, neuropsychology, ophthalmology, and exercise physiology. In addition, these professionals may work in different fields such as sports, neurorehabilitation, vestibular, musculoskeletal, community, vocational, and general practice clinical settings. Rehabilitation interventions for concussions employed in practice are also likely to use a blend of theoretical principles from motor control, cognitive, and psychological sciences. This scale of diversity can make information dissemination, collaboration, and innovation challenging. The Ten Movement Training Principles (MTPs) have been proposed as a usable and relevant concept to guide and support clinical reasoning in neurorehabilitation. When applied to concussion rehabilitation, these same 10 principles provide a comprehensive overview of key rehabilitation strategies for current and future practice. Future collaborations can use these training principles to support clinical and research innovations including the rapid rise of technologies in this growing field of rehabilitation practice.